Dr. Anyanwu: So, I am just going to present a case. This is a 64-year-old female who has no relevant prior history. She has got a two-week history of fever, malaise, and sweats. Her blood cultures are positive for enterococcus. She had an echocardiogram. I am going to show a very short clip, maybe Dr. Martin if you can just comment on this echo.
Dr. Martin: It is obviously a TEE and she has got a prolapsing mass that you are going to see severe two jets, probably of AI and probably has got leaflet destruction as well as vegetation. I am looking Ani, or want to look at that jet striking the anterior leaflet of the mitral valve, so I am always worried and I see it she has actually got a septic aneurysm of the anterior leaflet of the mitral valve. One of the key mistakes I think that echo guys can make from time to time is they get so entranced with looking at this veg on the aortic valve and the prolapsing leaflet that they do not look at the mitral, so the last thing you want to do is open up, go ahead and do an aortotomy and find out that you have got subvalvular mitral, So this is a big prolapsing mass and probably a secondary septic aneurysm of the anterior leaflet.
Dr. Carabello: Now, this patient is probably going to the OR anyway but is the mitral valve closing early?
Dr. Martin: Do they have acute severe AI ?
Dr. Anyanwu: Yeah, the patient has severe AI?
Dr. Martin: I can’t tell boys, but you know if you had that question, obviously that is where Dr. Craig Miller's color M-mode, just the M-mode of the mitral valve with an EKG would tell you that.
Dr. Carabello: I mean that is an important point.
Dr. Martin: You know, you do raise from time to time, you do make important points.
You can even a blind hog finds an acorn every once in while.
Dr. Martin: All right, do not be distracted by us. You have to jump in this game here.
Dr. Anyanwu: So, just to add on, there was normal left ventricular size and there was normal function. Otherwise, the findings are as stated. So, she has no signs of heart failure, she has not embolized. There is no suggestion of an abscess in the heart. She has now had antibiotics for two days and her fevers have subsided. So I am going to ask the audience to vote but when you finish voting, before we see the answers, I would like to know what the experts on the panel say. So what do you recommend at this point if you vote. Do you continue antibiotic therapy; there is no need for surgery? Do you operate emergently as soon as you can? Do you operate urgently in the next few days, semi electively in two to three weeks? Do you wait for the antibiotics to be completed and operate? So if you can vote.
Dr. Martin: You know, nothing is going to get better with this valve.
Dr. Anyanwu: So just keep voting, do not show us the answers.
Dr. Martin: I mean nothing is going to get better. The mitral valve is going to blow out at some point. Now, you going to have acute severe MR in the face of acute severe AI and you are going to be bubbling over in the corner. When I see vedges, now this is not a giant vedge there on the aortic valve, but I always want to more importantly to me is to see what is happening with the end organs. So, I want to know has she had an embolic event to her brain.
Dr. Anyanwu: No.
Dr. Martin: What do her kidneys look like?
Dr. Anyanwu: Kidneys are just fine.
Dr. Martin: Did you scan her brain or did you not?
Dr. Anyanwu: She is perfectly fine. She is supposed to go on a cruise two days later and indeed she wants to leave hospital and go on her cruise.
Dr. Martin: She is going to go on a cruise?
Dr. Anyanwu: Yeah.
Dr. Martin: All right, is she is going go down the Hudson River and just circle near your hospital ….
Dr. Anyanwu: No, no, she is going to Barbados.
Dr. Martin: She is going to Barbados. They have no pump programs in Barbados, they have good rum. She should drink a lot of rum.
Dr. Carabello For me, that is one of the reasons I asked a question about mitral valve pre-closure, if there were, I would say B. I would vote for surgery within 12 hours. With this case, I would say C.
Dr. Martin: I would say C.
Dr. Carabello I would say I want to do it. I do not want to wait three weeks. I would want to do it in the next day or two.
Dr. Martin: I do not think you are going to gain anything by waiting. I mean the infectious disease guys, they always get involved, and gals, will say we need to do antibiotics and all that. I think you are exactly right Blaise if she had acute severe AI and you got pre-closure in this operation right now but this mitral valve is going to go at some point.
Dr. Carabello We have reasonably good data that says that the chance of reinfecting the prosthetic valve even within 48 hours of positive blood cultures as long as they are on the right antibiotics is tiny, so I am not worried about that because I am going to operate on her, Steve is.
Steve: There are two surgical series now, one published out of University of Maryland, looking at urgent within 48-hour surgery and one is going to be presented by the STS from our place, taking 140 cases urgently done. Basically, the ability to have a good outcome is much higher now than it used to be in the old Darwinian thought where we would give the patient six weeks’ antibiotics and then operate on the patient. For two reasons, we worry about that; one where we operating on somebody who had an embolus or something to their head and turn that from a bland stroke to a hemorrhagic stroke and actuality in the Maryland series and ours that does not occur and I think that is an old wives’ tale, 25% of our patients had MRI lesions in their heads and not a single one turned hemorrhagic. The second thing is especially in the mitral position the ability to repair the mitral position or void an aortic abscess like she will have very soon is much higher if you treat her on antibiotics. So, our policy, and I think a lot of people have gone to this is sort of identify the bug, give them the most expensive antibiotics that the ID guys can think of and then take them to the operating room.
Dr. Anyanwu: Okay.
Dr. Martin: Audience, you all can join in, I mean, if you have questions or you want to just.
Dr. Carabello: Steve, do you care, or Ani do you guys care if you use an aortic homograph or does that not make any difference.
Dr. Anyanwu: We have not decided to operate yet, so I do not know. Can we see the answers.
So, most people want urgent surgery. A quarter feel we should wait until antibiotics are completed, so about half want to wait at least two to three weeks and the rest want to operate and 8% do not want to have surgery at all. I mean basically the concern here is that she is going to embolize, isn’t it? That is what we are worried about. This study published a few years ago in 2005, was a registry of almost 400 patients and they looked at factors that predicted embolization and importantly if you had vegetation more than 10 mm, it was predictive of new embolization as was mobility of the vegetation. Also the organism was quite important if you had Staph aureus you are more likely to embolize and indeed that is shown by other studies if you have Staph aureus, you are more likely to embolize. So, this patient had Enterococcus faecalis. The second issue has been which Dr. Bolling hinted is whether early surgery has worse outcomes and indeed there are data of such as this study published some months ago in the Annals suggesting that early surgery has worse outcomes than late surgery but of course there is a confounding factor because of the patients who are selected for early surgery might have been the sicker patients, but that is what is driving the decision either way and I am sure that is what drove people to vote one way or the other in the audience. So, we all discuss this, the cardiologists, the surgeons, infectious disease, and decided to wait maybe a week or maybe wait two weeks and then operate.
The patient is very informed. The daughter of the patient is a physician, an attending physician in my hospital, one of my colleagues, and the husband is a dentist so they are very well informed. They know the risks, they know pros and cons. She still wants to go on her cruise at this stage actually. So, she is still in hospital. Four days later, we say we will get a CT. Let us make sure there is no abscess in the heart before we are comfortable with our decision to delay surgery and look at her coronaries anyway.
The CT suggests there might be a perforation in the anterior leaflet. Both the coronaries are normal. We repeat the echo. There is definitely no vegetation; perforation is the same but the patient is changing. At this point the patient has dyspnea when she walks to the bathroom. She has got tachycardia. She has got a gallop, so things aren’t quite going fine. We move her to the CCU and we decide we are going to operate now because she now has a class I indication which is heart failure, so we decided we will operate the next day. On that evening, she had a TIA, and then she had several TIAs. We do an MRI and she has an acute infarct and also as you can see her middle cerebral artery on the left side is more or less gone. You can appreciate the thrombus in the internal carotid and if you look on the right of picture, which is our left side there are no blood vessels there. By midnight, she was hemiplegic and she lost her speech and she became incontinent. This is five days after antibiotics were started, so we had her in the CCU, we kept her blood pressure up and just watched. She is still hemiplegic. We did another MRI 20 hours later. There was no hemorrhage. The infarct is becoming more developed, still no blood going into her left hemisphere. So just to recap, we have a 64-year-old female with Enterococcus. She has got a kissing lesion on her mitral she has got mobile vegetation which has now embolized. She is 24 hours after a stroke. She is densely hemiplegic. She is aphasic. She has no mass effect and no hemorrhage and she has occlusion of her middle cerebral artery with no collateral flow and remember that she is in heart failure although that is controlled. Obviously, the considerations at this point are that is she still going to embolize further whether you operate or do not operate, whether she can transform into a hemorrhagic infarct or bleed into her brain whether you operate or do not operate and of course if you choose to operate you are operating on someone with effectively one carotid artery because there is no blood going down the rest so what happens when you put them on bypass and if you do operate you have someone who is hemiplegic that you have to rehabilitate after surgery. So what do you do at this point, so if you can vote again? So, you have got four options here. You can still continue antibiotic therapy that is still an option. Of course it’s all embolized anyway, so there is no problem.
Dr. Martin: I think you need an E on there, why operate urgently the first time, could you put that down there.
Dr. Anyanwu: It is too late. That's done now.
Dr. Carabello: But seriously let me ask one question.
Dr. Anyanwu: Yes.
Dr. Carabello: At the time when she deteriorated, formulating the opinion that she should go to surgery the next day. We did not reimage her at that time and I guess my question would be if we had reimaged her, would we have seen or could we have seen something on the images that would have pressed us instead of the next day.
Dr. Anyanwu: Actually, we did reimage her. I just didn’t put that information. You mean by echo. Yes, I did an echo which was unchanged.
Dr. Carabello: Unchanged, okay.
Dr. Anyanwu: Except that the left ventricle was probably mildly dilated.
Dr. Martin: I am surprised you did not blow out her mitral valve. I mean have seen so many like that anyhow, so now you want them to vote.
Dr. Anyanwu: Do you proceed to surgery now? Do you do surgery urgently but you want to wait at least one to two weeks because of the stroke? Do you do it semi-electively and wait four to six weeks? So if you vote. There is no point asking the panel what they will do because they wanted to operate yesterday so they will probably all operate.
Dr. Martin: I want to operate before she had a stroke.
Dr. Anyanwu: Oh, you would not operate anymore.
Dr. Martin: I said I wanted to operate before she had her stroke.
Dr. Anyanwu: And now she has a stroke.
Dr. Martin: Now, she has had worse than a stroke. I am not sure that…. you know, you have to look at her long-term prognosis, does she need urgent surgery, we are going to see what the audience says.
Dr. Anyanwu: Well, half the audience wants to wait. So, 40% want to wait one to two weeks and 16%.
Dr. Carabello: These cases to me are a lot like quicksand. The more you flail the deeper you get and so I am just not sure. I would say I think it is very unlikely that we would operate on somebody that had this devastating stroke in the near term.
Dr. Martin: No, I wouldn’t.
Dr. Carabello: I cannot give you any data to support that except to say I do not think we would.
Dr. Martin: Even though she has a daughter who is a physician. She is not a physician but her husband is a dentist, okay. What did the family want?
Dr. Anyanwu: Like you, they wished they had operated yesterday.
Dr. Martin: I mean what would they want for her now.
Dr. Anyanwu: Whatever you advised them, they will do. They will listen to you. I mean at this point in time, they are very distraught by it all. So, they are relying on you to make the decision.
Dr. Martin: So what did you do doctor.
Dr. Anyanwu: Can we go back down to the slides.
Dr. Martin: I sound like I work for the prosecution…, tell me doctor, what did you do? Well, I need to go and walk around. So you mean doctor…
Dr. Anyanwu: So anyway, Dr. Bolling hinted on this in his answer to the first question. Usually you should have waited two to four weeks because we are concerned about secondary neurological injury but the reality is that more recent data suggests that that is not the case. There are quite a handful of small series in the literature, I have just picked two. Where they have operated on people early after a stroke and they found no change in neurological symptoms and as Dr: Bolling says it might be that we have overstated the risk of hemorrhagic transformation of these infarcts. And of course there is also data from the cardiology literature where they have anticoagulated patients being treated medically and they found that if you look at the survival if anything the patients anticoagulated have better survival and they only saw major cerebral hemorrhage in 3% of patients and it was not related to anticoagulation so it might be that these patients do not necessarily bleed if you anticoagulate them. So we decided to go ahead and operate, so we operated the next morning and the rationale was, regardless of what we do, she is still in heart failure. As you said, she has still got severe aortic regurgitation. Dr. Carabello says the valve is going to blow out someday. She is going to be in a bad way, so the decision now is death or surgery really because realistically, she has got nowhere to go and she cannot start rehabilitating from her stroke until we fix her heart. So, we did operate on her and the findings are as you expect, the vegetation is not there anymore. Aortic valve is destroyed, and as you can see on the mitral valve, I do not have a pointer here, but we are looking through the aortic valve of the mitral leaflet and you can see that lesion you saw on the echo.
Dr. Martin: Right there.
Dr. Anyanwu: And that is the lesion taken out. It is not perforated fully but it would have at some point, so we are not having a big defect in the mitral when looking from the atrial side of the valve, so we would reconstruct that with pericardium. Some people will question why you did not replace this I hope not, so we replaced it with pericardium from the mitral side and put a ring and then put a stented tissue valve in the aortic position.
Dr. Martin: So you did a pericardial patch of the mitral?
Dr. Anyanwu: Yes.
Dr. Martin: And then a stented valve in the aortic position?
Dr. Anyanwu: Yes that is correct. So, she continued the antibiotics for six weeks and she went through rehab. She did not bleed into her brain. Her stroke did not get any worse and she is now able to mobilize still with some hemiparesis and she is still hemiparetic on the right side. She is dysarthric and dysphasic a bit but she is getting her voice back. So, just to comment, I mean this case reflects the controversy regarding endocarditis and vegetations and I think the balance of the emerging data suggesting that we probably should have been more aggressive initially and I think that the historical data that suggests the role for delayed surgery might not necessarily be applicable to the current era and there is a question of whether it is time to review the guidelines.
Dr. Anyanwu: Thank you.
Dr. Martin: All right, good case, thank you.